Inspection on 18/01/07 for Conifer Lodge

This inspection was carried out on 18th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Conifer Lodge 18/12/08

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Conifer Lodge 95/99 Pembroke Crescent Hove East Sussex BN3 5DE Lead Inspector Jennie Williams Key Unannounced Inspection 18th January 2007 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Conifer Lodge Address 95/99 Pembroke Crescent Hove East Sussex BN3 5DE Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01273 701888 01273 245918 MPC@ntlbusiness.com Macleod Pinsent Care Conifer Ltd Miss Josephine Carina Lowe Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is thirtyfour (34). Service users must be older people aged sixty-five (65) years or over on admission. New Registration Date of last inspection Brief Description of the Service: Conifer Lodge is a care home registered for thirty-four (34) places for people over sixty-five (65) years of age. No nursing care is provided at this home. District nurses will provide nursing input for those residents requiring this. Conifer Lodge is located in a quiet residential area of Hove. The care home is three separate homes that have been joined together for its current use. Residents’ bedrooms are located over three floors. There are stair lifts located in the home to assist residents to access all floors. There are twenty-four (24) rooms for single occupancy and five double rooms, all provided with en suite facilities. All rooms are currently being used for single occupancy. There are suitable numbers of toilet and bathing facilities located throughout the home to meet the needs of residents. There is a goodsized dining room and lounge room/conservatory and two other private communal areas for residents to use. Residents have access to a garden area at the rear of the home. There are some local amenities in the area and there is nearby access to public transport. There is limited parking available at the home and restricted paid parking in adjacent streets. Weekly fees range from £460 to £650 per week. There are additional fees; hairdressing (£9 to £25), chiropody (£9 or £10), beautician (£10 for full manicure), newspapers/magazines and personal toiletries (at cost). This information was provided to the CSCI on the 18 January 2007. Prospective residents find out about the home through social services referrals, word of mouth and from themselves/relatives living in the area. Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Conifer Lodge will be referred to as ‘residents’. New owners took over the running of this home in December 2005. This unannounced key inspection took place over eight hours on the 18 January 2007. Eight residents, of both genders, were spoken with during the inspection. Fifteen residents were offered an opportunity to speak to the Inspector in private if they wish. One resident did not wish to be involved in the inspection process and this was respected. Twelve resident surveys were sent to the home of which seven were returned. Two were returned due the residents no longer residing at the home. Two care plans were viewed and specific areas of care were looked at in two other care plans. The Registered Manager and seven staff members were spoken with during the inspection. Ten staff surveys were sent to the home of which four were returned. One was returned due to this staff member no longer working at the home. Five staff files were inspected. Ten relative/visitors comment cards were sent to the home following the inspection, however none of these have been returned. Out of five GP comment cards sent out prior to inspection, three were returned. A comment card was sent to a Community Psychiatric Nurse (CPN), which was returned. Three comment cards were sent to social workers/care managers. One of these was returned. The comment card sent to an advocate was also returned. A pre-inspection questionnaire was received prior to the inspection. A tour of the environment was provided and some individual rooms were viewed. Fire records and medication procedures were inspected. The quality assurance system was discussed and complaint records were inspected. The staff rota and menus were viewed. The Inspector ate lunch with the residents. Apart from fire records, no other health and safety records were viewed as this information has been provided in the pre-inspection questionnaire. There were 22 residents residing at the home on the day of the inspection. What the service does well: Residents were complimentary about the staff working at the home and felt that their personal care needs were being met. Prospective residents are provided with opportunities to visit the home prior to moving in to ensure the home will meet their needs. Residents felt that their privacy and dignity are Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 6 respected. All residents residing at the home remain generally independent and require only some assistance with their personal care needs. Visitors are welcomed at the home and residents may receive visitors in private. Residents were complimentary about the provision of food at the home. Residents are provided with regular fulfilling activities. Residents feel comfortable and know how to make a complaint and feel that they will be listened to. Residents are happy with their individual rooms and are able to personalise them. Staff receive training appropriate to their roles to ensure their safety and that residents needs continue to be met. Procedures in place for the handling of personal allowances ensure residents’ finances are safeguarded. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4, 5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The pre-admission assessment process ensures that only residents whose needs can be met are admitted and prospective residents are provided with an opportunity to visit the home prior to admission. Intermediate care is not provided at the home. EVIDENCE: All prospective residents are assessed prior to admission. Information is obtained from other health professionals wherever applicable. The pre admission assessments viewed provided the home with clear information on the needs of the individual and demonstrated that the home does not admit anyone whose needs cannot be met at the home. There was one assessment that had not been fully completed by the home, however social services information was obtained. The Registered Manager informed the Inspector Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 9 that they were unable to undertake a full assessment due to the lack of privacy within the setting of the assessment. The Administrator/Deputy Manager confirmed that there was no one residing at the home from any minor ethnic community or social/cultural/religious groups with any specific needs or preferences. Staff individually and collectively have the skills to deliver the services and care which the home offers to provide. Residents/relatives are provided with an opportunity to visit the home prior to admission. The majority of residents spoken with confirmed that they or a relative had visited the home prior to admission. Three resident surveys received demonstrated that they received enough information about the home before they moved in so they could decide if it was the right place for them. One comment written was ‘the manageress was very careful to explain everything – and all questions were answered fully’. The home does not have dedicated accommodation to provide intermediate care. Respite care is provided if there is a spare place available. Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being met with the information provided in the care plans on the assessed needs of residents. Residents are safeguarded by the medication procedures in place. EVIDENCE: Care plans provide clear information for staff on how to meet the assessed needs of individuals. Care plans were seen to be reviewed monthly and are drawn up with the involvement of the individual. There is a care plan summary that provides carers quick information on the individuals’ preference on daily routines. These were noted to be signed the resident. Residents residing at the home are fairly independent. The home undertakes a falls risk assessment for each individual, however the two assessment forms in use provided some conflicting information. These were discussed with the Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 11 Registered Manager who will address this minor shortfall and ensure the forms compliment each other. Residents spoken with all confirmed that their personal care needs are being met at the home. Of the residents that were asked, all confirmed that staff encourage them to remain as independent as they are able. All resident surveys received demonstrate that they receive the care and medical support they need. Two GP comment cards showed that staff demonstrate a clear understanding of the care needs of residents. All three comment cards received confirmed that any specialist advice given is incorporated into the resident’s plan of care. Two other health professional comment cards received demonstrated that they have had limited contact with Conifer Lodge, however no concerns were raised. The Registered Manager confirmed that there are no residents with pressure sores and the home has access to pressure relieving equipment when needed. Residents observed to be wearing glasses and hearing aids all confirmed that eyesight and hearing tests are arranged when required. A deputy manager confirmed that there are policies and procedures in place for all aspects dealing with medication. The content of these were not read. Medication Administration Record (MAR) charts viewed demonstrated that medication is being signed for at the time of administration. It was confirmed that all staff administering medicines have received training. Accurate records were being maintained of controlled drugs. There are records kept of incoming and outgoing medication. Residents are provided with an opportunity to self medicate, based on a risk assessment being undertaken. It is recommended that guidance be incorporated into an individual’s care plan regarding the level of selfmedication. Reports provided to the CSCI demonstrate that appropriate action is taken in the event of a medication error being made. All residents spoken with confirmed that their privacy and dignity are respected. It was confirmed by residents and observed by the Inspector that staff knock on residents’ room doors prior to entering. Staff were observed to have a good professional rapport with the residents and were heard to be calling by their preferred term of address. Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ lifestyle within the home is their own choice and residents are provided with sufficient stimulation to fulfil their interests and needs. Residents choice and preferences are catered for with meals. EVIDENCE: Residents and staff spoken to felt there were enough activities provided at the home. Staff initiate activities every afternoon and outside entertainment regularly visits the home. The home keeps an activities folder that records what is happening in the home and has a good collection of photos available for people to look at. One resident survey received showed that there are always activities available for them to participate in. Three comment cards stated that the individuals choose not to participate and prefer to stay in their own rooms. Residents spoken with confirmed that their lifestyle within the home is their choice. They choose what to wear and when to get up and go to bed etc. Residents are encouraged to bring in personal possessions with them to Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 13 personalise their own rooms. One comment made to the Inspector was ‘if nothing was wrong with me, I would still want to be here’. Of the residents that were asked, all confirmed that they would not want to make any changes within the home. Residents are encouraged to continue with activities they may be involved in within the community prior to admission. There are no restrictions imposed on visiting relatives/friends. Residents are able to leave the home unescorted when they wish. Risk assessments are undertaken for this activity, if staff have concerns regarding an individual. Residents spoken with were complimentary about the food provided. The Inspector enjoyed gammon, pineapple and vegetables with the residents for lunch. There is a choice of meals available. Residents were observed to be enjoying the meal and lunchtime appeared to be unhurried. Staff were observed to be nearby to offer discreet assistance should anyone require. Meals and menus are discussed at quarterly resident meetings. There is a list of residents’ likes/dislikes provided to the cooks to ensure residents choice and preferences are catered for. Three resident comment cards stated that they always like the meals and two stated they usually like the meals provided at the home. Comments received ranged from ‘very good’, ‘always a choice’ to ‘excellent’. One resident who had specific dietary needs stated ‘… the staff do their best to provide suitable meals for me’. There were 15 residents having lunch in the communal dining area. Residents are able to choose where they wish to eat their meals. Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are dealt with appropriately, reassuring those involved that they are being listened to and that action will be taken, if necessary. Safeguarding Adults procedures ensure residents are safeguarded. EVIDENCE: The home has a suitable complaints procedure that all involved with the home has access to. No complaints have been made directly to the CSCI. There has been three complaints made directly to the home since the last inspection. Records are maintained of complaints and what action is taken. Records demonstrate that the home investigates these in an unbiased manner and appropriate action is taken where needed. Residents surveys received demonstrated that residents know who to speak to if they are not happy about something and know how to make a complaint. Of the residents that were asked, all confirmed that they know who to speak to if they had any concerns and feel comfortable making complaints. A complaints book is kept and refers the reader on where to find the relevant correspondence. Some information is kept within an individual’s folder. The Registered Manager confirmed that she will be reviewing this process and is Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 15 going to keep one central complaints file so all information pertaining to a complaint is in one area. There has been one Safeguarding Adults (Protection of Vulnerable Adults (POVA)) referral made in the last 12 months. The home followed correct local procedures and was co-operative with the local authority investigating team. The allegation was found to be not upheld, however appropriate action was taken by the home to ensure the residents and staff members were safeguarded. The Registered Manager has undertaken the local authority’s POVA course designed for managers on action required in the event of an allegation of abuse being made. Staff spoken with and staff files viewed evidenced that staff receive training in the Safeguarding Adults. All staff surveys demonstrate that they are aware of adult protection procedures. Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and homely environment and are provided with comfortable indoor and outdoor communal facilities. EVIDENCE: Rooms are located over three floors and there are stair lifts available to assist residents to access all areas of the home. Some bedrooms have five steps that residents must be able to mobilise to reach these. The pre-inspection questionnaire demonstrates that a lot of decoration has been undertaken within the home since the new owners have taken over. There are grab rails placed throughout the home in areas where residents may require some assistance with mobilisation. Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 17 There are no hoists available at the home. A telephone conversation was had with the Registered Manager following the inspection, who confirmed that if a resident falls and not hurt, the individuals are supported to raise themselves from the floor. If someone is hurt and unable to get up, the ambulance service is called. The Registered Manager confirmed that she is looking into the budget to purchase equipment to assist in raising residents following a fall. Residents confirmed that they were happy with their rooms. With the resident’s permission, the Inspector viewed some individual rooms. These were observed to be personalised to reflect the personality and character of the individual. Residents spoken with confirmed that they were able to bring personal items with them when moving into the home. One of the communal lounges is used as a designated smoking area for those residents who chose to smoke. There is a resident’s room adjacent to this area. A staff member confirmed that the resident residing in this room is also a smoker, so the smell of smoke permeating into this room is not an issue for this individual. The pre-inspection questionnaire demonstrates that a variety of decoration and refurbishment within the home has been implemented since the new owners have purchased the home. Any shortfalls noted that pose a risk to the safety of the residents have been highlighted in the below section, Management and Administration. , The home was clean and free from offensive odours on the day of the inspection. Residents’ surveys demonstrate that the home is always fresh and clean. The pre-inspection questionnaire demonstrates that there are policies and procedures in place for infection control and a company is contracted to dispose of any soiled waste/clinical waste. Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being met with the number and skill mix of staff on duty and are safeguarded by the recruitment procedures. EVIDENCE: Residents were very complimentary about the staff working at the home. Staff spoken with confirmed that they generally enjoyed working at the home. All residents and staff spoken with confirmed that there were sufficient numbers of staff on duty at all times. There is usually three care staff working in the mornings and two care staff working in the afternoons. There is always a senior staff member and ancillary staff working in addition to the care staff. There are two care staff working at night. One night worker undertakes other duties, however is always available to assist the other carer with residents when the need arises. Comments received about the staff ranged from ‘very good’ to ‘excellent’. Four out of five staff files inspected demonstrated that robust recruitment procedures had been followed. References are obtained on all prospective employees and application forms are completed. Staff have an enhanced Criminal Record Bureau (CRB) check undertaken and the home ensures a POVA First check is received prior to staff commencing employment. One Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 19 worker had commenced work without a POVA First check having been undertaken by the home. There was a CRB form completed one week prior to this from a different employer. This was discussed with the Registered Manager who confirmed that this person did not provide care to the residents and was supervised at all times. All other required recruitment checks had been undertaken for this individual. It was reiterated to the Registered Manager that a staff member should not commence employment prior to at least a POVA check being received. Staff spoken with confirmed that they are kept up to date with all mandatory training and are provided with enough training opportunities. Recent training undertaken included: POVA, manual handling, infection control, first aid and fire training. The home has commenced using the new Common Induction Standards that were implemented last year. A carer, who had no previous care working experience, confirmed that they felt the induction process was good. Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally run in the best interest of residents. Residents’ financial interests are safeguarded. Residents will be better safeguarded when the work is completed to maintain a safe environment. EVIDENCE: The Registered Manager is registered with the CSCI and has 25 years of experience working in the care industry in a variety of roles and settings. She has completed the Registered Manager Award course. The majority of staff confirmed that management are supportive and approachable. It was confirmed by staff and residents that there has been no major changes made to the running of the home since the new owners took over the home. Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 21 There were concerns raised by the Registered Manager during the registration stage of the new owners. She was overdue for an appraisal and felt there were no clear lines of accountability within the home and with external management. The Registered Manager confirmed that these shortfalls have now been addressed with the new owners. The Registered Manager confirmed that there is a quality assurance and quality monitoring system in place where regular feedback is sought from residents, district nurses and GP’s. Resident meetings are held quarterly. The Registered Manager has recently undertaken an analysis of the feedback and will be making these results available for anyone to view and will be made available with the Service Users Guide for prospective residents. Staff meetings are held every one to two months. A staff member has recently been appointed the role of Quality Assurance Supervisor to ensure the building/individual rooms and the presentation of staff are checked regularly and are maintained to a satisfactory standard. No one employed at the home is an appointee for any resident. Personal allowances are held at the home for some residents. Records viewed demonstrated that receipts are maintained for all financial transactions and clear accurate individual records are kept. Other residents have their own arrangements in place regarding their own personal finances. It was observed that some radiators without guaranteed low surface temperature remain unguarded. Hot water taps were observed not to be regulated and temperatures ranged from 50°C to 63°C. The Registered Manager confirmed that there is a programme in place to address these shortfalls. It was recommended that risk assessments be put in place until suitable action has been taken. The Registered Manager and staff spoken with all confirmed that all staff are kept up to date with mandatory training. The pre-inspection questionnaire demonstrates that fire alarms are tested weekly and a fire risk assessment was undertaken 30 November 2006. Staff confirmed and records viewed showed that staff last received fire training in February 2007. No other health and safety records were inspected on this occasion as this information has been provided in the pre-inspection questionnaire. Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP38 OP38 Regulation 13(4) 13(4) Requirement That hot water is delivered around the recommended 43°C. That radiators are guarded or are of guaranteed low surface temperature. Timescale for action 31/03/07 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations That guidance be incorporated into an individual’s care plan regarding the level of self-medication. Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Conifer Lodge DS0000066109.V299813.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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